ECTOPIC PREGNANCY (PowerPoint)

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					DEFINITION
  Implantation of the fertilized ovum outside the normal endometrial
cavity.
                                 INCIDENCE
1/200 of all pregnancies, but recently the incidence is increasing due to:
    1.Availability of better methods for diagnosis.
    2. Assisted reproduction techniques.
    3. Wide use of IUCD
    4. The use of progestogen only contraception, which decrease the tubal
       motility.
    5. Increased incidence of sexually transmitted diseases as Chlamydia.
    6. Tuboplasty for treatment of infertility.
    7. Previous ectopic pregnancy.
AETIOLOGY

1.Congenital hypoplasia of the tube, which become long, narrow and fibrous, also congenital
 accessory ostia, diverticuli.

2.Previous tubal surgery: either to perform sterilization or to restore patency, as the tube is usually
 not healthy.


3.Chronic salpingitis: the commonest cause kinking and partial tubal occlusion ± focal destruction
 of mucosa.

4.Endometriosis    Peritubal adhesions     kinking.


5.Functional causes: altered tubal motility e.g. progestogen only oral contraceptive pills (OCPs),
 morning after pill, IUCD, induction of ovulation.

6.Neoplastic e.g. broad ligament myoma stretching and distorting the tube, broad ligament cyst or
 ovarian cyst pressing on the tube.


7.Transperitoneal migration of the ovum.

8.Rapid development of the trophoblast, excessive decidual reaction in tubal mucosa
                 PATHOLOGY OF TUBAL ECTOPIC PREGNANCY

   Sites of implantation of the fertilized ovum in the tube:
    - Ampulla (commonest).                         - Isthmus.
    - Interstitial part.                           -Fimbria (least common).

   Tubal pregnancy usually becomes disturbed 6-8 weeks after implantation because:
    - Decidua is defective and unable to resist invasion by the trophoblast.
    - Muscle wall is thin and unable to stretch.

   Timing of rupture of tubal pregnancy: depends on the site of implantation
    - Isthmical portion (narrowest): 2 wks after conception.
    - Ampullary portion (widest): up to 10-12 wks.
    - Interstitial portion: up to 16 weeks (thick myometrium capable of distension and
      stretching but may be fatal due to increased vascularity).
                              A. The Fallopian Tube:
1.Rupture of the pregnancy sac towards the lumen leads to one or more of the
 following:
  Haematosalpinx (Tube distended with blood).
  Tubal mole (Haematoma of relatively longer duration)

  Tubal abortion (Extrusion of contents to peritoneal cavity)
  Blood passing through the abdominal ostium             will lead to peritubal
   haematoma or pelvic haematocele.
2.Rupture of the tube to the outer surface: may occur spontaneously or
 following coitus or bimanual examination.
  Rupture towards the roof of the tube leads to:
   - Paratubal haematoma and pelvic haematocele.
   - Diffuse intraperitoneal hemorrhage
   - 2ry peritoneal pregnancy
  Rupture towards the floor of the tube leads to broad ligament haematoma.
B. The uterus:
 Soft and slightly enlarged up to 6-8 weeks (effect of hormones produced by
  the corpus luteum).
 After disturbance of the tubal pregnancy, shedding of the decidua will occur

  leading to vaginal bleeding.
                        CLINICAL PICTURE
I. Undisturbed tubal pregnancy:
    Suspected in a patient with a predisposing factor and confirmed by
investigations
Symptoms:
  Symptoms of early pregnancy.

  Unilateral dull pain in lower abdomen.




Signs:
 Lower abdominal tenderness, (unilateral tender adnexa).

 Tenderness on mobility of the cervix during bimanual examination.
                       II. Disturbed tubal pregnancy
   Classical picture described usually with tubal abortion associated with mild
internal bleeding.

Symptoms:
 Short period of amenorrhea: duration of amenorrhea depends on timing of

  disturbance of tubal pregnancy, which depends on site of implantation.
 Pain: present in every case:

  - Unilateral dull aching pain (tubal distension before rupture)
  - Stabbing pain (tubal rupture).
  - Colicky pain (tubal abortion).
  - Bladder and rectal pain (pelvic haematocele)
  - Shoulder pain (irritation of the diaphragm by blood on lying down).
 Vaginal bleeding: after the pain, mild, due to shedding of the decidua.

 Fainting: hypovolaemia and irritation of the peritoneum by blood.
Signs:
General examination:
 Sign of hypovolaemia

  1. Pallor              2. Rapid weak pulse         3. Low blood pressure.
 Temperature: normal, slightly decreased or slightly increased due to

                 blood absorption.
Abdominal examination:
 Lower abdominal tenderness, rebound tenderness and rigidity, especially

  on one side.
 Shifting dullness may be present.

Vaginal examination:
 Bluish, soft, moist, vagina and soft cervix (signs of pregnancy).

 Tenderness in the posterior or lateral fornices.

 Marked pain on moving the cervix.

 On bimanual examination: the uterus is soft and slightly enlarged.

  Irregular tender adnexal mass (difficult to be felt due to marked
  tenderness and rigidity).
III. Acute Picture:
  (Picture of severe intraperitoneal haemorrhage)

  As before with: Sudden sever abdominal pain followed by collapse.

  On examination: marked shock, which exceeds the amount of bleeding,

   shifting dullness.

IV. Chronic cases with pelvic haematocele
The patient usually gives:
  History of disturbed ectopic pregnancy.

  Lower abdominal discomfort, dysuria, and tenesmus.

  Pallor, rapid pulse, slightly raised temperature.

  Vaginal and bimanual examination:

   Tender cystic swelling in the posterior fornix.
   Uterus is soft, slightly enlarged and pushed forward.
(Pelvic haematocele may become infected leading to pelvic abscess)
                                               INVESTIGATIONS
1. Pregnancy test in urine:
   A -ve test does not exclude pregnancy as the level of β- H            C G   in   u r in e

m a y b e b e lo w         t h e s e n s it iv it y o f th e t e s t .




2. Serum β- H C G :
  More sensitive, more accurate.

  A -ve test excludes pregnancy.

  No doubling after 48 hours indicates abnormal pregnancy (if the condition

   of the patient allows waiting for 2 days).

3. Ultrasound:
  No intra-uterine pregnancy sac (Empty endometrial cavity) β                      m ost

     im p o r t a n t s ig n .

  Decidual reaction in the uterus thick endometrial lining.
  Tubal or adnexal mass, which may show fetal echo or even fetal heart

   (Detection of embryonic echoes or pulsations in ectopic pregnancy is the
   exception rather than the rule)
  Fluid (blood) in Douglas pouches is usually present and is one of the

   most important clues in diagnosis.
4. Combined serum β- H C G a n d u l t r a s o u n d ( D i s c r i m i n a t i o n z o n e ) :
  Abdominal U/S shows intra uterine pregnancy sac when serum β- H                               C G

     l e v e l is > 2 0 0 0 m iu / m l .

    Vaginal U/S shows intrauterine pregnancy sac when serum β- H                      C G   le v e l

     is     8 0 0 m iu / m l .

    Ectopic pregnancy is diagnosed if no intrauterine pregnancy is seen by
     U/S at the above-mentioned levels of β- H C G .

5. Laparoscopy: of great value, both diagnostic whenever in doubt and
  therapeutic in early and undisturbed cases.

6. CBC: detect anaemia, leucocytosis (to exclude inflammatory conditions).

7. Urine analysis: to exclude pyelitis.

8. Curettage: if done will show decidual reaction and absence of chorionic
  villi and fetal tissue.

N.B.: Bimanual examination under anaesthesia: to feel the ill-defined
irregular adnexal mass is dangerous as it may lead to severe bleeding
from the affected tube
                   DIFFERENTIAL DIAGNOSIS
1. Abortion:
  Bleeding occurs before pain.

  Pain is colicky, suprapubic, radiating to the lower back.

  Bleeding is increasing in cases of missed or inevitable.

  No tenderness or rigidity in the abdomen.

  U/S reveals an intra uterine pregnancy.

2. Salpingitis:
  Bilateral pain and tenderness in the lower abdomen.

  Yellowish offensive discharge.

  Rapid full pulse.

  High fever.

  Serum β- H C G a n d U / S r e v e a l s n o p r e g n a n c y .

3. Acute appendicitis:
  Pain begins at umbilicus but later settles at McBurney’s point.

  Serum β- H C G r e v e a l s n o p r e g n a n c y .

4. Hemorrhage in corpus luteum cyst:
    Similar symptom (period of amenorrhea, pain, and then bleeding) but:
βH C G , U / S a n d l a p a r o s c o p y a r e d i a g n o s t i c .
5. Pelvic haematocele:
    Should be differentiated from masses in Douglas pouch.
                TREATMENT of TUBAL PREGNANCY
General condition should be corrected

I. Salpingectomy:
  Indications: disturbed tubal pregnancy in a shocked patient.

  Correction of shock is done simultaneously with laparotomy.




II. Conservative management:
(This means preservation of the affected tube).
  Indications: Young patient desiring pregnancy with undisturbed tubal

   Pregnancy.
  Disadvantages: recurrence of tubal pregnancy.
A. Conservative surgery (through laparotomy or laparoscopy).

1. Linear salpingostomy
  Linear incision in the anti-mesenteric border to evacuate the tube, ensure

   haemostasis.
  The tube is left open to heal by 2ry intention to avoid stenosis.



2. Linear salpingotomy:
   As salpingostomy but the incision is sutured.

3. Segmental resection and end-to-end anastomosis: for pregnancy in the
 isthmical portion of the tube rarely indicated, difficult and predisposes to
 obstruction

4. Milking of the tube (expression through the fimbria) for pregnancy near
the fimbria.
B. Non-surgical management (Methotrexate):

 I.M. or intra-tubal (guided by U/S) to destroy the trophoblast.
 Indication: young patient with undisturbed tubal pregnancy, pregnancy sac

  < 3 cm in diameter, serum β- H C G < 1 5 0 0 0 m i u / m l , h a e m o p e r i t o n e u m n o t
    m o re   th a n   5 0   m l w ith c a re fu l fo llo w   u p   a s   th e   tu b a l p re g n a n c y m a y ru p tu re

    e v e n a fte r in je c tio n n e e d in g s u rg ic a l in te r v e n tio n .



N.B.: In all cases anti-Rh antibodies are given if the patient is Rh -ve and
the husband is Rh +ve
    Clinical picture as tubal pregnancy but-it is differentiated from it at
laparoscopy or laparotomy by “Spiegelberg criteria”.
 a.It occupies the positions of the ovary.
 b.It is attached to the uterus by the ovarian ligament.
 c.The tube on the affected side is intact.
 d.Ovarian tissue is found in the sac by pathological examination.
Treatment: Removal of the affected ovary.
 The fertilized ovum is implanted in the cervix below the level of the internal os
  producing a barrel-shaped cervix and hour-glass uterus.
 It produces painless bleeding after a missed period.

 Treatment:

  In a young patient: try ligation of the cervical arteries and methotrexate.
  Total Hysterectomy.
 Disturbance of pregnancy is usually late (at the 4th or 5th month).
 At laparotomy: it is differentiated from interstitial tubal pregnancy by relation of

  the round ligament to the pregnancy sac
 Treatment: excision of the affected horn.
  It is either: primary in the peritoneum or
   secondary following tubal rupture.
  The fate of the fetus:

    Usually dead, it even may be mummified or
     calcified.
    If living it is mal-developed
  Diagnosis:

    Abnormal fetal lie and presentation the
     uterus is separate from fetus.
    U/S.
    Treatment: blood should be available and
     immediate laparotomy to remove the fetus.
     If the placenta is attached to a vital organ:
the cord is ligated short, the placenta is left for
autolysis and we may give methotrexate.

				
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Description: An ectopic pregnancy, or eccysis, is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic ...